Cases & Commentaries
- Spotlight Case
One day after reading only the first line of a final ultrasound result (which stated that the patient had a thrombosis), an intern reported to the ICU team that the patient had a DVT. Because she had postoperative bleeding, the team elected to place an inferior vena cava (IVC) filter rather than administer anticoagulants to prevent a pulmonary embolism (PE). The next week, a new ICU team discussed the care plan and questioned the IVC filter. The senior resident reviewed the radiology records and found the ultrasound report actually stated the thrombosis was in a superficial vein with low risk for PE, which meant that the correct step in management of this patient's thrombosis should have been surveillance.
Commentary by Anna Parks, MD, and Margaret C. Fang, MD, MPH
A pregnant woman presented to the emergency department 3 times in 4 days, first with symptoms of upper respiratory infection, nausea, and fever; then abdominal cramps; then shortness of breath and abdominal pain. On the third visit, she was diagnosed with influenza and possible sepsis. In between visits, the patient had been taking acetaminophen (1g every 4 hours) to control her fever. Although she had signs of acute fulminant hepatitis due to acetaminophen overdose, administration of the antidote, N-acetylcysteine, was delayed for 10 hours.
Commentary by Stephen Bacak, DO, MPH, and Loralei Thornburg, MD
Emergency medical service (EMS) providers obtained an electrocardiogram (ECG) in a woman who had developed severe chest pressure at home. The ECG revealed an ST-elevation myocardial infarction (STEMI). Unfortunately, the ECG failed to transmit to the emergency department (ED) while EMS was en route, so a "Code STEMI" was not activated. Unaware of the original ECG results, ED clinicians obtained a repeat ECG that did not demonstrate the earlier ST segment elevations, and the patient was admitted to the telemetry unit for monitoring overnight. The next morning, lab results revealed an elevated troponin level and another ECG demonstrated she had a large heart attack the previous day. Although the patient was rushed to the cardiac catheterization laboratory, the delay in treatment led to significant loss of cardiac function.
Commentary by Robert E. O'Connor, MD, MPH
Perspectives on Safety
Nursing and Patient Safety
Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at University of Pennsylvania. She is generally considered the nation's foremost expert on health policy as it relates to the nursing workforce. We spoke with her about how nurse staffing and the work environment can affect patient safety and outcomes.
This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.